Provider Demographics
NPI:1023807716
Name:SPACECOASTPOP LLC
Entity type:Organization
Organization Name:SPACECOASTPOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:321-243-5255
Mailing Address - Street 1:331 MELBOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4315
Mailing Address - Country:US
Mailing Address - Phone:321-243-5255
Mailing Address - Fax:321-243-5255
Practice Address - Street 1:601 E STRAWBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4733
Practice Address - Country:US
Practice Address - Phone:321-301-0411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPACECOASTPOP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty